Is there a conflict of interest behind your cancer diagnosis?

My mother was astonished when I told her about the national Open Payments database that was launched by the Affordable Care Act. “You mean I can see all the money drug companies have given to a doctor? Even my doctor?” We plugged her doctor’s name into the database and up it popped, associated with a number of payments. He had recently prescribed an expensive, brand-name drug for my mother; she had questioned whether a cheaper, older alternative might be just as good. It turned out that her doctor had received payments from the company producing that brand-name drug.

I don’t know, of course, if her doctor’s recommendation had been influenced by these payments or if his choice represented the best medication for her. What I do know is that my mother lost trust in her care provider at that moment.

Many people have looked up their internist or surgeon in the Open Payments database. My guess is that few have looked up their pathologist. A study that I recently carried out with several colleagues suggests that they should.

Many people benefit from the services of a pathologist like me, even if they don’t often see us in person. We are responsible for most of the laboratory testing that takes place, including the diagnosis of nearly every cancer.

Today, pathologists don’t restrict themselves to just diagnosing disease. Through the use of tests called “companion diagnostics,” pathologists also help determine whether a patient may be eligible for specific targeted treatments, such as Herceptin for breast cancer or Keytruda for a variety of cancers.

These powerful drugs come with hefty price tags. Modern cancer treatments routinely cost more than $100,000 per year. The manufacturers of these drugs and their companion diagnostic testing know that pathologists play an essential role in determining who gets these costly drugs.

Our recent analysis of Open Payments data showed that about 1 in every 4 pathologists receives money or other benefits from drug and medical device companies. About 40 percent of the total money to pathologists came from companies producing companion diagnostics or the treatments that follow from these tests. That’s a lot of industry payments for doctors who don’t prescribe a single drug. The biomedical industry, however, is not a careless investor. Given the high cost of drugs like Keytruda and others whose use depends on companion diagnostics, even a small influence over the pathologists who may act as gatekeepers for them can produce an enormous return on investment for the industry.

Although some pathologists receive tens of thousands of dollars from industry, the average industry payment to them is low, less than $100. But that doesn’t mean these payments have little or no influence. Previous research has shown that even meals worth $20 or less may affect physician decision-making.

How might industry payments influence pathologists’ decisions? We can turn to many different tests to diagnose a disease. Which tests are used, and how many, are often up to our discretion. A surgeon or other doctor sends us your tissue, we run the tests we deem appropriate, and you get the bill. Imagine taking your car to a mechanic and not getting a say in what repairs get done. This is the situation with much of laboratory testing.